I n t e g r i t y - S e r v i c e - E x c e l l e n c e

Cassandra D Howard, Col, FS, MC, TNANG 164 MDG/CC, Memphis, TNAANGFS, Vice-President

Cassandra.Howard@ang.af.mil

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Photo source: ANG Creative, Health Professions Recruiting Campaign

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Headquarters U.S. Air Force

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Endurance Management Ground Initiative

Air Force Medical Operating Agency

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Basic

Sle

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Basic

Sle

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Sleep or Die

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Impact of Fatigue Sleep Physiology Circadian Rhythm Consequences Recognition No-Go Pills

Overview

I n t e g r i t y - S e r v i c e - E x c e l l e n c e

Impact of Fatigue

FedEx Flight 1478FedEx Flight 1478American Flight 1420American Flight 1420

Korean Air Flight 801Korean Air Flight 801China Air Flight 006China Air Flight 006

2 people injured, AC major structural damage 228 killed, AC destroyed

11 killed, AC destroyed 3 severely injured, AC destroyed

Fatigue Related Crashes

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Impact of Fatigue

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Major Accidents

Three Mile Island

Challenger Space Shuttle

Exxon Valdez

The Cost

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The Evidence Major Accidents Annual Cost

Military Strategy Human Performance

Impact of Fatigue

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Aeromedical Causal Factors

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Exploit the Enemy’s Weakness

While remembering

our own limitations

Military Strategy

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0102030405060708090

100

Home Away MNF MNFHome

MNFAway

WestEast

Monday Night Football

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Effect of operations on Effect of operations on sleep and circadian physiologysleep and circadian physiology

FATIGUEFATIGUE

Sleep Sleep lossloss

CircadianCircadianrhythmsrhythms

Types of FatigueAcute:Work inducedChronic:Repeated sleep lossSubjective:Stress inducedCircadian Rhythm:Shift Work or Jet lag

Causes of Fatigue

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Sleep – A Vital Physiological Function Sleepiness Affects Waking Performance, Vigilance,

and Mood Sleep Loss Accumulates Into A Sleep Debt Physiological Versus Subjective Sleepiness The Circadian Pacemaker

Basic Human Physiology:Sleep & Circadian Rhythms

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Stages 1 & 2 Stages 3 & 4 Physical Restoration Hormone Production Tissue Repair

Dreams Muscle Twitching Rapid Eye Movement Problem Solving Short- to Long-Term

Memory

NREM NREM SleepSleep

REM REM SleepSleep

Physiology of Sleep

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NREM Sleep

REM Sleep

WakeWake

REMREM

Stage 1Stage 1

Stage 2Stage 2

Stage 3Stage 3

Stage 4Stage 4

2400 0100 0200 0300 0400 0500 0600 2400 0100 0200 0300 0400 0500 0600 07000700

What’s Supposed To Happen(Normal Sleep Histogram)

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Wake

REM

Stage 1

Stage 2

Stage 3

Stage 4

2400 0100 0200 0300 0400 0500 0600 0700

REM - Mental restoration

NREM - Physical restoration

Sleep Histogram

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Sleep-Wake Temperature Mental Performance Hormones Digestion

Types of Physiological Rhythms

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SleepSleep No SleepNo Sleep

98.698.6

96.596.5 MaximumMaximumSleepinessSleepiness

2400 0600 0900 1200 1500 18002400 0600 0900 1200 1500 1800

Body Temperature

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0900 1200 1800 0000 0600 09000900 1200 1800 0000 0600 0900

HighHigh

LowLow

MaximumMaximumAlertnessAlertness

Alertness Level

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After 17 hours of sustained wakefulness, performance decreased to a level similar to .05 BAC

After 24 hours of sustained wakefulness, performance decreased to a level similar to .10 BAC

Center for Sleep Research, University of South Australia,Center for Sleep Research, University of South Australia,and University of Adelaide, South Australia (Nature, 1997)and University of Adelaide, South Australia (Nature, 1997)

Fatigue, Alcohol and Performance

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Fatigue, Alcohol and Impairment

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Forgetful

Poor decisions

Slowed reaction time

Reduced vigilance

Poor communication

Fixated

Apathetic

Lethargic

Bad mood

Nodding off

Fatigue Signs & Symptoms

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Physiological mechanisms underlie fatigue Just like water and food,

sleep is a physiological necessity Fatigue can have

severe consequences Financial Human performance

Take sleepand fatigue seriously

If You Remember Nothing Else…

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Fight The Good Fight Combating Fatigue

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Preventive Strategies Minimizing sleep loss Naps Good sleep habits Effects of food, alcohol, and exercise Sleep environment Circadian strategies

Fatigue Countermeasures:Personal Strategies

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Preventive Strategies:Sleep Loss & Strategic Napping

Sleep Requirements and Debt Strategic Napping (Prior to Duty)

Can Acutely Improve Alertness Limit Nap: 10 - 30 Minutes Decreases Continuous Wakefulness

Some Sleep is Better Than None

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Wake

REM

Stage 1

Stage 2

Stage 3

Stage 4

2400 0100 0200 0300 0400 0500 0600 0700

• Best method to minimize fatigue• Limit to 10 or 20 minutes Try not to nap within 5 hours bedtime

• Avoid sleep inertia Disorientation and lethargy for 5-20 mins

Sleep Histogram

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Preventive Strategies:Good Sleep Habits

Regular Sleep/Wake Schedule Develop/Practice Regular Pre-Sleep Routine Avoid Heavy Meals Avoid Alcohol and Caffeine Physical/Mental Relaxation Techniques No Sleep in 30 Minutes…Get Out of Bed

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Preventive Strategies:Sleep Environment

Dark, Quiet Room White Noise Comfortable Temperature Comfortable Sleep Surface Large Meals & Indigestion Lack of Food

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Self-Medication

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2000 B.C….Here, eat this root.1000 A.D….Roots are heathen.

Say this prayer.1850 A.D….Prayer is superstition. Drink this potion.1940 A.D….That potion is snake oil.

Swallow this pill.1985 A.D….That pill is ineffective.

Take this antibiotic.2000 A.D….That antibiotic is artificial.

Here, eat this root.

Supplements and the Human Trend

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• Effects of Medications• Desired Effects – treats the symptoms• Side Effects – other effects on the body• Allergic Reactions • Combined Effect – 1 + 1 = 3

• Companies combine antihistamines and decongestions to off set each other

•Over-the-Counter Medications•Antihistamines = sedation, drowsiness•Decongestants = nervous, dizzy, sleepy•Cold preps = most contain alcohol

Self-Medication

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Personal Strategies:Operational Countermeasures

Physical Activity Combats Sleepiness Social Interaction and Conversation Diet and Hydration Bright Lights Strategic Caffeine Consumption

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Strategic Caffeine Use

15 to 30 minutes to take effect Effects can last for up to 3-4 hours

Chocolate 1-35 mg caffeine 1 oz Pepsi 36 mg caffeine 12 oz Coke 46 mg caffeine 12 oz Mt Dew 54 mg caffeine 12 oz Instant Coffee 40-108 mg caffeine 5 oz Drip Coffee 90-150 mg caffeine 5 oz

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Sleep Food

•Carbohydrates•Pasta•Corn•White Bread•Potatoes

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Alert Foods

• Protein

• Nuts and Seeds

• Meats/Cold Cuts

• Peanut Butter

• Cheese

• Eggs

• Fish

• Yogurt

• Beans

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“No Go” Pills

AF guidance (vol 3) <= 7 consecutive days (Sonata <=10 consecutive days) <= 20 in a 60 day period (Sonata <= 28 in a 60 day period)

FS Recommendations As little as needed (but they can help jet lag) Bad sleep is not an Ambien deficiency

Melatonin is a no-go that’s a no-go

Medication Dose Half-life GroundingTemazepam (Restoril®) 15 or 30 mg 8.0-12.0 h 12 hours

Zolpidem (Ambien®) 10 mg 2.0- 2.5 h 6 hours

Zaleplon (Sonata®) 10 mg 1.0 h 4 hours

Ground testing required prior to operational use.

I n t e g r i t y - S e r v i c e - E x c e l l e n c e

Smart Phone Apps

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Android iPhoneBedtime Calculator (Free)

- REM cycle monitoringCrew Alert ($29.99)

- Your wildest dreams come true!

Sleepy Time (Free)- Chromotherapy

Sleep Science Alarm ($.99)- REM cycle monitoring

Sleep Watcher (Free)- Daily fatigue estimation

Fatigue Calculator (Free)- Daily fatigue estimation

Relax and Sleep Plus (Free)- Ambient noises

aSleep 3 ($.99)- REM cycle monitoring

- Chromotherapy

Sleep Now! (Free)- Ambient noises

Circadian Alarm ($.99)- REM cycle monitoring

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Summary

Impact of Fatigue Sleep Physiology & Circadian Rhythms Consequences & Recognition Preventive Strategies Operational Countermeasures No Silver Bullet, No Magic Pill